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A Cardiometabolic Subspecialty? Not Such A Crazy Idea

A Cardiometabolic Subspecialty? Not Such A Crazy Idea

The global epidemic of metabolic syndrome, a constellation of cardiometabolic risk factors, and that of obesity, type 2 diabetes, atherosclerosis, and cardiovascular disease (CVD) have become the modern-day health hazard across the world. In the US, the numbers are particularly striking. Even with the recent reports that the incidence of diabetes fell by 35% in the last 20 years1 , there are more than 30 million US adults living with diabetes, 1.5 million Americans are diagnosed with diabetes every year, and 84 million have prediabetes.2 The increasing prevalence of obesity (now estimated to affect more than 93 million, or nearly 40% of all US adults), high cholesterol (95 million US adults have cholesterol levels of >200 mg/ dL), and hypertension (46% of US adults using the new guidelines), together with type 2 diabetes (T2D) are some of the major drivers in cardiovascular morbidity and mortality, and altogether causing billions if not trillions of dollars to the US economy.3-5
At Cardiometabolic Health Congress, we have been at the forefront of looking at the whole spectrum of cardiometabolic disease, including obesity, diabetes, lipids, hypertension, cardiovascular disease, and practical ways to address them. We strive to synthesize and translate the latest developments across the different fields to promote evidence-based strategies to tackle this growing epidemic. As these diseases or risk factors exist in a continuum, they can’t be addressed individually or in a vacuum, which is unfortunately what tends to happen in clinical practice. As CMHC Chair Robert H. Eckel, MD and Michael J. Blaha, MD, MPH describe in a powerful editorial published in The American Journal of Medicine, “patients are shunted back and forth among cardiologists, endocrinologists, and primary care physicians—with uncertain “ownership” of different aspects of the patient’s care.” As such, meaningful change in patients outcomes continue to elude us, as the statistics above show
Arguably, the times have never been better for cardiometabolic medicine. With the results of cardiovascular outcomes trials of newer diabetes drugs like sodium-glucose-cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists (GLP1 RAs), we now have real means to prevent heart failure (HF), stroke, myocardial infarctions, and all-cause mortality in patients with T2D and existing CVD, and perhaps, soon enough, even in patients without T2D, or for primary CVD prevention.7,8,9 Furthermore, these agents have shown real promise in tackling the massive challenge of slowing kidney disease progression in patients with diabetes, in addition to having beneficial effects on hypertension and overweight and obesity.7,8 We have discovered the ‘metabolic face’ of heart failure, which has led to not only improved treatments for the often ignored spectrum of patients with heart failure and diabetes, but also in characterizing a new subset very tightly related to cardiometabolic risk factors, or HF with preserved ejection fraction (HFpEF).10 These developments only represent a small portion of the exciting advances that are poised to revolutionize the care for patients with cardiometabolic disease or risk.
But will they do so, or will they be subject to the slow uptake (sometimes in decades)11 that usually is associated with newer therapies and approaches? The early indications do not seem promising. A recent study from the GOULD registry, an on-going US-based registry designed to describe real-world treatment patterns among patients with ASCVD, including those with T2D, showed that in eligible patients with existing ASCVD and T2D, only 9% and 7.9% were using an SGLT-2 inhibitor or a GLP-1 RA, respectively.12 In this study, the use of therapies that, at best, have no cardiovascular benefits in high-risk patients with T2DM, such as sulfonylureas and DPP-4 inhibitors, was significantly higher than that for GLP-1 RAs or SGLT-2 inhibitors.12 Because of the cardiovascular benefits of these agents, there is considerable discussion about using them (particularly SGLT-2 inhibitors) in the cardiology setting, and even calls to merge diabetes and cardiology.13 But, cardiologists still seem skeptical about using these agents, or may be ill-equipped to do so.6,14 Also, what is it to say that even if we get past the hurdle of the widespread adoption of these agents across specialties, that we can really address the tremendous impacts of cardiometabolic diseases without taking into account nutrition, physical activity, smoking, hypertension, or lipids?6
Optimizing and coordinating a comprehensive treatment plan for a patient with cardiometabolic disease that takes into account all these factors can be extremely challenging, confined not only by deficiencies in training, but also financial and health system barriers. While there are no easy solutions to this, an interesting proposal is to create a new cardiometabolic subspecialty training track in internal medicine, so in the near future we can have physicians that are better equipped and specialized to address all these different aspects. The proposal, as laid out by Drs. Eckel and Blaha6 , would involve 3 years of specialized training that would be a composite of cardiology, endocrinology, and advanced concepts in lifestyle medicine. The endocrinology component would include extensive training in obesity, diabetes (both type 1 and type 2), as well as lipids and lipoprotein disorders, while the cardiology component would be focused primarily on the primary and secondary prevention of ASCVD. Lifestyle training would go beyond just inquiring about diet and exercise; the cardiometabolic clinician would have the ability to address nutrition and diet, smoking cessation, and recommend individualized physical activity goals. Although the idea is in its initial stages and a lot of groundwork needs to be done, the authors make a compelling argument for challenging the current status quo for the care of patients with cardiometabolic disease. As the authors conclude: “it’s time to move forward and not wait until we wish we had. The answer should not be to add more training, but to sharpen and focus existing education concepts to produce the product we know we need.”6
Shpetim Karandrea, PhD
Editorial Director

    References:

    1. Benoit, Stephen R., et al. “New directions in incidence and prevalence of diagnosed diabetes in the USA.” BMJ Open Diabetes Research and Care 7.1 (2019): e000657.
    2. American Diabetes Association. “Statistics about diabetes.” Available at http://www.diabetes.org/diabetes-basics/statistics/, accessed August 6, 2019.
    3. Centers for Disease Control and Prevention. “Adult obesity facts.” Available at https://www.cdc.gov/obesity/data/adult.html, accessed August 6, 2019.
    4. Centers for Disease Control and Prevention. “High cholesterol facts.” Available at https://www.cdc.gov/cholesterol/facts.htm, accessed August 6, 2019.
    5. Benjamin, Emelia J., Paul Muntner, and Márcio Sommer Bittencourt. “Heart disease and stroke statistics-2019 update: a report from the American Heart Association.” Circulation 139.10 (2019): e56-e528.
    6. Eckel, Robert H., and Michael J. Blaha. “Cardiometabolic Medicine: A Call for a New Subspeciality Training Track in Internal Medicine.” The American Journal of Medicine (2019).
    7. Carbone, Salvatore, et al. “Glucose-lowering therapies for cardiovascular risk reduction in type 2 diabetes mellitus: State-of-the-Art Review.” Mayo Clinic Proceedings 93.18 (2018): 1629 – 1647.
    8. Das, Sandeep R., et al. “2018 ACC expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes and atherosclerotic cardiovascular disease: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways.” Journal of the American College of Cardiology 72.24 (2018): 3200-3223.
    9. Gerstein, Hertzel C., et al. “Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial.” The Lancet (2019).
    10. Sunder, M. D. “Heart Failure with Preserved Ejection Fraction: A Review of the ACC/AHA Guidelines and Evidence-Based Management Strategy.” The Medicine Forum 20.1 (2019).
    11. Packer, Milton. “Why it’s still 1989 for primary care.” Medpage Today. July 03, 2019, available at https://www.medpagetoday.com/blogs/revolutionandrevelation/80822, accessed August 7, 2019.
    12. Arnold, Suzanne V., et al. “Use of Guideline-Recommended Risk-Reduction Strategies Among Patients with Diabetes and Atherosclerotic Cardiovascular Disease: Insights from Getting to an Improved Understanding of Low-Density Lipoprotein Cholesterol and Dyslipidemia Management (GOULD).” Circulation (2019).
    13. Vardeny, Orly, and Muthiah Vaduganathan. “Practical Guide to Prescribing Sodium-Glucose Cotransporter 2 Inhibitors for Cardiologists.” JACC: Heart Failure 7.2 (2019): 169-172.
    14. Young, Randy. “Cardiology & diabetes: collaborating to defeat a dangerous duo.” CardiovascularBusiness, available at https://www.cardiovascularbusiness.com/topics/lipids-metabolic/ cardiology-diabetes-collaborating-defeat-dangerous-duo, accessed August 9, 2019.

    Volume

    October 2019 | Vol. 2 Q4